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National standards of healthcare cleanlinessSpecifications, methodology and good practice

September 2019

NHS England and NHS Improvement

The NHS Long Term Plan says that when organisations work together they provide better care for the public. That is why on 1 April 2019 NHS Improvement and NHS England united as one –

our aim, to provide leadership and support to the wider NHS. Nationally, regionally and locally, we champion frontline staff who provide a world-class service and constantly work to improve the

care given to the people of England.

Contents

Foreword.........................................................................................2

Introduction......................................................................................4

Infection prevention and control....................................................10

Pest control....................................................................................16

Health and safety..........................................................................20

Cleaning responsibilities framework..............................................28

Safe cleaning frequencies.............................................................29

General Principles of Cleaning and Disinfection...........................30

Risk categories and standards for functional areas......................35

Auditing and monitoring information..............................................45

Audit process.................................................................................59

Audit reporting...............................................................................72

PLACE and the National standards of healthcare cleanliness......73

Cleaning operating procedures.....................................................74

Governance...................................................................................76

Glossary........................................................................................78

References....................................................................................80

Acknowledgements.......................................................................83

1 | Contents

ForewordProviding a clean and safe environment for healthcare is a key priority for the NHS and is a core standard in the Health and Social Care Act 2012, which recognises the role of cleaning in minimising the risk to patients from healthcare-associated infections.

NHS bodies and independent providers of healthcare and adult social care in England (including primary dental care, independent sector ambulance providers, and primary medical care providers) have a further responsibility. The code of practice for preventing and controlling infections, and related guidance, says they must adequately resource local provision of cleaning services. They should also have a strategic cleaning plan and clear cleaning schedules and frequencies so that patients, the public and staff know what they can expect.

Providing a clean and safe environment, coupled with increasing public concern about healthcare-associated infections, means healthcare establishments must not only be clean but able to demonstrate how, and to what standard, they are being cleaned.

The National standards of healthcare cleanliness 2019 apply to all healthcare environments. They combine mandates, guidance, recommendations and good practice. The standards will be regularly revised and updated so they are current, reflect good practice and encourage continuous improvement. We have designed this document to be easy to understand, and it includes supporting advice, suggested cleaning methods and templates.

Since the first publication of national cleaning standards in 2001, NHS managers have welcomed the opportunity to measure performance in a uniform way, and to benchmark it against similar healthcare environments. A collaborative approach is essential to continuously improve cleanliness: you can benefit from significant influence by involving a board nominee, clinical colleagues, partner organisations and patients in setting and monitoring cleaning standards for consistently high levels of service.

Healthcare establishments have the flexibility to decide how to organise their cleaning resources. However, meeting these standards is mandatory and where

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explicit, local managers must follow them. The Health and Social Care Act 2012 and the Care Quality Commission Regulation 15: Premises and Equipment require healthcare premises to be cleaned to national standards. Applying both the standards and the monitoring and auditing processes in this document can help healthcare establishments demonstrate their compliance. Additionally, implementing the standards will help reduce the risks associated with poor cleanliness, demonstrate due diligence and promote consistent and high quality outcomes for patients, the public and staff.

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IntroductionThese standards provide a framework within which healthcare organisations in England should set out details for providing cleaning services and assessing ‘technical’ cleanliness and the efficacy of the cleaning process. The standards apply in all healthcare environments and regardless of the way cleaning services are provided. They replace the National specifications for cleanliness in the NHS 2007 (and amendments) published by the National Patient Safety Agency.

The standards do not advise on precisely how cleaning services should be provided – for example, by direct employment or contracting out. Such matters are for local determination. Ultimately, local managers are accountable for the effectiveness of cleaning services. The standards do provide clear advice and guidance on:

• what is required

• how organisations can demonstrate the way(s) in which cleaning services will meet these requirements

• how to assess performance.

We recognise that healthcare is delivered in a variety of settings, and these standards and guidance are for all of them: acute hospitals, mental health, community, primary care, dental care, ambulance trusts, GP surgeries and clinics, and others.

Compliance with the standards, and the auditing processes, should be written into contracts with cleaning service providers. Cleaning service managers and providers should read this document thoroughly and ensure all staff are aware of its contents. All those involved in providing healthcare cleaning services should work towards high quality, safe cleaning services that meet the needs and expectations of patients, the public and other healthcare environment staff, to contribute to the overall patient experience and to high quality patient-centred care.

We recognise that high levels of cleanliness can only be achieved through:

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• clear specifications

• training and developing staff

• documented lines of accountability and responsibility

• involving patients

• all personnel recognising their responsibilities

• a meaningful framework for measurement

• management board support, the appointment of a nominee to represent cleaning-related issues at board level, and board ownership to embed cleanliness as part of the organisation’s strategy

• direct links between healthcare directors of infection prevention and control, local infection prevention and control teams, and facilities management (FM) teams.

Aims and objectives

The standards seek to provide a common understanding of what it means to be a clean healthcare setting. The aim is to improve the quality of the NHS by ensuring all cleaning-related risks are identified, minimised and managed on a consistent, long-term basis, irrespective of where the responsibility for providing cleaning services lies.

Delivering a high quality cleaning service is complex, demanding and not to be underestimated. However, always keep in mind that the single most important factor is the outcome of the service.

The definition of cleaning in its simplest term is ‘the removal of unwanted material without damaging the surface to which it adheres’. In a healthcare environment, ‘unwanted material’ includes dust, debris, marks and spillages, as well as micro-organisms that can harm patients. The environment therefore needs to be visibly clean, as well as clinically clean: i.e. meeting safe standards appropriate to the healthcare setting.

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These standards focus on the technical outcomes of cleanliness as well as the methodology to achieve these outcomes. It is important that the methodology is consistent with good practice and meets infection prevention and control guidelines, since the responsibility for day-to-day arrangements rests entirely with individual healthcare organisations.

The standards are flexible so they apply to all healthcare settings. They include advice on which areas might be allocated within each functional area, but ultimately this is a local decision.

Good practice suggests individual healthcare organisations set their own aims to achieve safe standards. These should be realistic, achievable, challenging and regularly reviewed to ensure they contribute to continuing improvement.

An effective healthcare cleaning service should:

• be patient and customer-focused

• provide clarity for all personnel responsible for ensuring the healthcare environment is clean and safe

• enhance quality assurance systems

• address governance and risk assessment

• be consistent with infection prevention and control standards and requirements

• meet the requirements of CQC outcome standard Regulation 15

• set clear outcome statements that can be used as benchmarks and output indicators

• have clear objectives that provide a foundation for service improvements

• be flexible to meet the needs of specific healthcare environments, circumstances and priorities

• be future proof

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• provide for a culture of continuous improvement

• be flexible, to meet the ongoing needs of operational service delivery

• consider the health, safety and wellbeing of patients, public and staff.

The standards can be used as:

• a basis for developing specifications for service-level agreements or local procedures

• a benchmark against which to compare services

• an aid to establishing the optimum levels of resource to deliver safe cleaning standards

• part of an ongoing performance management process

• a framework for auditing and monitoring

• a support tool for improving patient and visitor satisfaction.

Context

The national specifications for cleanliness in the NHS were launched in April 2001 as the National standards of cleanliness. In December 2004, the word ‘standards’ was replaced with ‘specifications’ to avoid confusion with the Healthcare Commission’s Standards for Better Health (now the Care Quality Commission). The National standards of healthcare cleanliness 2019 has reintroduced the term ‘standard’ to reinforce that all NHS healthcare establishments in England must adhere to this document.

The national specifications have been reviewed and revised to ensure they take account of changes since the last review – specifically, but not restricted to:

• Publicly Available Specification: PAS 5748:2011 and PAS 5748:2014

• National specifications for cleanliness in the NHS 2012: guidance on setting and measuring performance outcomes in primary care medical and dental premises

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• The revised healthcare cleaning manual (AHCP) 2013

To provide accessible, flexible and transferable standards, we have based our recommendations on sound evidence, (see References, page 74) and accepted good practice relating to using equipment and avoiding the transfer of healthcare-associated infections in the UK.1

The standards supersede the Healthcare cleaning manual, revised by the Association of Healthcare Cleaning Professionals (AHCP) in 2013. Together with the Health and Social Care Act 2008 and associated updates 2015, these provide an assurance framework to support compliance with the core cleanliness standard and the code of practice. The cleaning operating procedures referred to are provided for guidance only.

1 https://www.gov.uk/government/collections/healthcare-associated-infections-hcai-guidance-data-and-analysis https://www.england.nhs.uk/wp-content/uploads/2015/04/10-amr-lon-reducing-hcai.pdf https://improvement.nhs.uk/resources/healthcare-associated-infections/

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https://improvement.nhs.uk/resources/healthcare-associated-infections/

https://www.england.nhs.uk/wp-content/uploads/2015/04/10-amr-lon-reducing-hcai.pdf

https://www.gov.uk/government/collections/healthcare-associated-infections-hcai-guidance-data-and-analysis

https://www.gov.uk/government/collections/healthcare-associated-infections-hcai-guidance-data-and-analysis

Commitment to Cleanliness Charter

The Commitment to Cleanliness Charter sets out an organisation’s commitment to achieve a consistently high standard of cleanliness in all its healthcare facilities. It includes the functional risk category, cleaning frequencies and cleaning responsibilities for each functional area.

The charter references the new star rating system which reflects the cleanliness of the whole area regardless of who has responsibility for cleaning, demonstrating that organisations are serious about providing a safe clean environment.

Displaying the charter is a requirement for all organisations. A template has been provided so that all charters are of the same standard and format throughout the NHS and easily recognisable for patients, the public and staff. The charters must be displayed where they can be seen – for example, in or near ward and department entrances, outside lift areas for public and circulation areas, or in waiting rooms.

There will inevitably be areas where it is not practical to site a charter, such as in an ambulance. Whenever an organisation believes it cannot display a charter it must seek a derogation to confirm that this is acceptable. To apply for a derogation, organisations must submit their completed charters to [email protected] explaining how they propose to make them easily accessible.

Organisations can edit the charters to insert logos and contact details. However, displaying certain information in the posters is a requirement to provide patients, public and staff with important information about cleanliness. For this reason, some fields and headings are fixed and cannot be changed, such as cleaning task, cleaning frequency and responsibility.

Appendix 5 contains a table with more information on how to complete the charter, as well as editable versions and worked examples. It includes templates for all functional risk areas and for blended areas. We recommend the charter is printed on A3 size paper as a minimum so it is easy to read.

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mailto:[email protected]

Infection prevention and control

These standards support local risk management plans by providing a framework for assessing the effectiveness of cleaning programmes. The director of infection prevention and control – or nominated lead for non-NHS providers – and the infection prevention and control teams must be involved in their use and regularly told the results of assessment, monitoring and audit.

Personal responsibility and accountability are crucial to maintaining a clean and safe environment. The objectives set should reflect the deliverable outcomes for cleanliness, to incorporate them into the healthcare organisation’s core business through performance frameworks and ensure staff are held to account for them.

Overview

The essence of good cleaning is that things not only look clean, but that they are clean. All users of healthcare premises have a right to assume the environment is safe and fit for purpose.

Classification of infection risk and cleaning frequencies

Different spaces will require different types and frequencies of cleaning depending on the activities carried out and the level of infection risk. These factors must be taken into account by the organisation when agreeing the cleaning frequencies.

Staff should take care to read and fully understand the required frequencies of cleaning that apply to their work areas and to follow them closely. When room use or priorities change this should result in a review of the cleaning frequencies for the area.

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National colour-coding scheme

A national colour-coding scheme is widely applied throughout healthcare organisations and is well-embedded in the sector. We highly recommend that organisations adopt the scheme.

The scheme’s intention is to significantly reduce the risk of cross-contamination between different types of area and to ensure that patients, public and staff can easily observe this safe working practice by recognising the colours used.

Under the scheme, all cleaning materials and equipment – for example, cloths (reusable and disposable), mops, buckets and non-disposable gloves are colour coded. The method used to colour code items is clear and permanent.

Cleaning products (i.e. chemicals and detergents) do not need to be colour coded. The code does not extend to catering equipment (for example, chopping boards and knives) where already well-recognised and well-established procedures address food hygiene and food separation issues.

The colour scheme colours are shown in Figure 1 below.

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Figure 1: National colour-coding scheme

Source: Association of Healthcare Cleaning Professionals

Responsibilities of the individual employer

Under health and safety law, an employer has a legal duty to protect employees and others (agency workers, contractors) from the risks of workplace injuries and ill-health, including work-related dermatitis.

An organisation is required to ensure all staff have had the appropriate training in using gloves and personal protective equipment (PPE).

Disposable, colour-coded plastic aprons for cleaning activities

Disposable, colour-coded plastic aprons should be worn for all cleaning tasks in which splashes to clothing are likely. They may also need to be worn when cleaning rooms occupied by patients nursed in isolation for specified infections. This should be clearly indicated in method statements.

For certain specialised cleaning tasks (for example, flood response) where contamination of clothing by large amounts of fluid is likely, the use of overalls and waterproof footwear may be indicated by a risk assessment.

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Accidental exposure to blood or substances

Inoculation injuries, such as needlestick, other sharps injuries, bites, scratches and splash contamination of broken skin require immediate action:

• the area should be washed with soap and running water, and bleeding should be encouraged

• the wound should not be sucked

• a waterproof dressing should be applied.

The staff member should contact either the occupational health department or the accident and emergency department for further advice, whichever is specified by the healthcare provider’s policy. The incident should be reported to a manager who should ensure it is recorded.

For splashes to intact skin, the affected area should be washed immediately with warm soapy water.

Splashes to the mouth should be rinsed out with large quantities of water and reported.

Splashes to the eyes should be irrigated immediately with water – or, if available, sterile saline from an eye station – and reported.

Spillages of bodily substances

‘Bodily substances’ refers to fluid or tissue issuing either directly from a patient or indirectly in the form of a specimen or otherwise. The most common types that staff with cleaning responsibilities may encounter include wound exudate, blood, sputum, urine and faeces.

Spillages may be cleaned up by either nursing/departmental staff or cleaning staff; each healthcare provider’s local policy on cleanliness will have clear instructions on responsibility for this. It is vital that any staff member performing this duty has received the specific training for this type of spillage cleaning and follows the method statement fully.

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Uniforms and jewellery

The guidance in this section is consistent with the Department of Health’s uniform and workwear guidance 2007.2

Hand and wrist jewellery can harbour micro-organisms and can reduce compliance with hand hygiene. Wristwatches and jewellery should be removed at the beginning of the shift, and trust or organisation policy should be followed. The local infection prevention and control team should be consulted on individual compliance issues.

Sleeves on uniforms should either end above the elbow or be kept rolled up above the elbow when undertaking cleaning duties.

Staff should change into a clean uniform before each shift. If a staff member’s uniform becomes visibly contaminated or soiled, they should change uniforms at the earliest practical opportunity.

Uniform should be worn only while on duty, except where a local healthcare provider policy specifies otherwise.

Only issued uniform should be worn while on duty. Cardigans and jumpers should not be worn while undertaking duties.

Wearing numerous badges should be avoided. An official identification badge is acceptable.

Waste management

Waste management is the generic term for a range of waste-associated activities – specifically its generation, handling, storage and transportation from point of source (i.e. treatment or consultation room) to final place of disposal (i.e. recycling, alternative treatments and composting or incinerator). Improper waste management risks staff safety and could affect a wider network of people including patients, visitors and waste contractors.

It is a trust’s responsibility to ensure legal compliance around the segregation of waste and they must be aware that they have a responsibility for waste from cradle to grave and therefore need to understand the different disposal routes for all the

2

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waste they produce. In addition to this they should be aware of the variant costs associated with different disposal methods.

The segregation, collection, storage, handling, transportation and disposal of waste must be undertaken with care and in line with local policy and procedure.

Organisations should ensure that cleaning processes and systems, including the adoption of this standard, reflect what is required to comply with local policy relating to waste. All waste management activities should also comply with national guidance and good practice, (see links below to Health Technical Memorandum -Management and disposal of healthcare waste 078433). As a starting point, consider:

• roles and responsibilities relating to waste

• waste training

• waste classification, categories (streams) and colour coding

• waste storage and transport arrangements

• personal protective equipment and standard precautions

• application and use of waste disposal equipment

• risk management and incident reporting

• spillage management procedures, including accidental exposure.

In the event of a needlestick injury following the handling of waste bags, the injured person should attend accident and emergency in the first instance and local policy should be referred to.

Cleaning and waste management are intrinsically linked. The safe and effective management of both areas relies on the successful application of the other. http://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/Publicationsandstatistics/

Publications/PublicationsPolicyAndGuidance/DH_078433

https://www.gov.uk/government/publications/guidance-on-the-safe-management-of-healthcare-

waste

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https://www.gov.uk/government/publications/guidance-on-the-safe-management-of-healthcare-waste

https://www.gov.uk/government/publications/guidance-on-the-safe-management-of-healthcare-waste

http://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078433

http://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078433

Pest controlPest control and management is an essential component in the provision of safe and hygienic healthcare facilities. Pest activity can pose unacceptable risks to patients, staff and visitors, additionally they can have a negative impact on reputation and public confidence and cause damage to the environment or food products. It is therefore essential that organisations have in place effective and appropriate pest control management policies, procedures, contracts/services and systems.

Organisations should procure licensed specialist contractors to support with pest control. Pest control contracts or service specifications should be developed with consideration for the following:

• Different sites, environments and geographical areas will have different common pest issues. Organisations should ensure that the pest control contract / service they procure is reflective of local need. The most common pests usually fall into one of four categories, rodents (i.e. rats and mice), crawling insects (i.e. ants, fleas, cockroaches, silverfish, bed bugs), flying insects (i.e. wasps, bees, hornets, moths, flies) and birds (i.e. pigeons)

• The specification should identify priority levels for the different types of pests covered. The priority levels should take into account how common the pests are and what risks they pose

• The specification should be setup to prioritise pest activity/infestation in high risks areas i.e. clinical areas and near food areas

• The specification should be clear if the service is required to be proactive, reactive or a combination of the two:

o Proactive Service – Routine scheduled visits to monitor, bait and inspect

o Reactive Service – A call-on service which is provided in reaction to pest activity or evidence of pests

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• The specification should detail a process for any works identified, whether this is reported back to the organisation or it is progressed by the contractor. Areas which are conducive to pest activity should be managed and ingress points for pests should be removed (proofing)

• The specification should detail expected riddance timeframes for the pests covered. This should take into account the specific pest, the risk it poses and how long effective treatment will take. Additionally, it should detail an initial response time for visits following a report of activity

• Pest control provision should cover both internal and external areas

Service reports should be provided by pest control contractors/service providers on every visit. These reports should include the date and time of the visit, areas or locations inspected/treated, pest activity identified, any treatment/work completed and next steps and recommendations (i.e. proofing or housekeeping).

It is recommended that where pest concerns exist organisations should undertake surveys/detailed inspections (via contractors/specialist personnel) to identify factors that may contribute to, or sustain, potential pest control issues or infestations. This will include recommendations on proofing work and other factors such as housekeeping.

Due to the nature of pest control work, and its associated risks, contractor/service providers should be required to complete detailed risk assessments to determine the most favourable treatment option for pest infestation and what control measures will be put in place. Organisations should ensure that pest control work is undertaken safely and legally, as such they should require that contractors/service providers:

• Use pesticides and methods of work / application that are appropriate and comply with all relevant Health and Safety legislation and best practice (i.e. HSE - Health and Safety Executive)

• Provide full details and methodology on all pesticides, products and methods that are to be used

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• Be able to provide COSHH (Control of Substances Hazardous to Health) data sheets relating to all pesticides used, risk assessments and method statements (RAMS)

• Keep all equipment and goods safe and under control, with all pesticides clearly and correctly identifiable by labels on all containers

• Create a physical barrier or display appropriate signage/warning notices where insecticidal dusts have been used barring entry until products and contaminants have settled

• Remove all waste materials after completion of any pest control activities

Organisations should also have in place a local pest control policy along with any required underlying procedures. It is recommended that the local policy includes:

• Roles and responsibilities in relation to pest control management

• Local definition of pests covered within the policy

• Contractor/service provider details covering aforementioned aspects of this section

• Contractor/service provider arrangements i.e. proactive, reactive or combined

• Contract/service specification levels

• Expected response and riddance times for the pests identified

• Health and Safety requirements and considerations

• Monitoring of performance

Good cleaning, hygiene and housekeeping is critical in the management and control of pests and issues with standards can both cause pest activity and impact on the riddance time and effectiveness of pest control processes. Particularly food/drink waste and debris are a significant contributory factor that should be prioritised. Organisations should promote staff compliance with good housekeeping practices in order to help limit pest control incidents and issues.

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Pest control provision should be undertaken in partnership, and with full consideration for cleaning, food and waste services in order to be as effective as possible. Cleaning routines can disturb baits if not properly controlled. Internal and external waste areas should be kept clean and free from spillages and receptacles should be fit for purpose.

Food preparation and service areas should be kept clean and tidy and a ‘clean as you go’ approach is recommended. Food should only be stored in pest proof sealed containers and food waste and spillages should be dealt with and disposed of promptly and appropriately.

Pest control should also fully comply with local infection prevention and control (IPC) policy and procedure in relation to reportable infestations, for instance ‘human carrier’ pests such as fleas or mites and ectoparasites (i.e. lice and scabies). It is likely that organisations will have specific policies and procedures to cover some, if not all, of these infestations or occurrences.

Pest control contracts, services, policies and procedures should be monitored and reviewed as required locally to ensure they continue to meet the needs of the organisation.

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Health and safetyIntroduction

Health and safety at work is everyone’s responsibility; protecting the health and safety of employees or members of the public who may be affected by your activities is an essential part of risk management and must be led by the board. The board should set the direction for effective health and safety management.

The Health and Safety at Work etc. Act 1974 states that employers must:

• assess risks to employees, customers, partners and any other people who could be affected by their activities

• arrange for the effective planning, organisation, control, monitoring and review of preventive and protective measures

• have a written health and safety policy

• ensure they have access to competent health and safety advice

• consult employees about their risks at work and current preventive and protective measures.

All employees must follow the training they have received when at work and using any work items; they should take reasonable care of their own and other people’s health and safety and co-operate with their employer on health and safety. Employees should tell someone (employer, supervisor or health and safety representative) if they think the work or precautions are putting anyone’s health and safety at serious risk.

All employees should receive health and safety training appropriate to their role and responsibilities. The following guidance provides a basic starting point that all staff should be familiar with before carrying out cleaning activities. It is not intended to be an exhaustive list, and staff should be encouraged to report any concerns about the safety of any aspect of their duties to their supervisor before beginning.

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Control of substances hazardous to health

Cleaning in a healthcare environment requires the use of chemical agents, and this is potentially dangerous. Employers are therefore required to protect employees and others who may be exposed to them by complying with the Control of Substances Hazardous to Health Regulations 2002 (COSHH) (as amended).

COSHH sets out eight basic measures employers must take:

• assess the risks

• decide what precautions are necessary

• prevent or adequately control exposure

• ensure control measures are used and maintained

• monitor the exposure

• carry out appropriate health surveillance

• prepare plans and procedures to deal with accidents, incidents and emergencies

• ensure employees are properly informed, trained and supervised.

An employer must prevent – or if this is not reasonably practicable, control –exposure to hazardous substances and provide staff with information, instruction and training about the risks, steps and precautions the employer has taken to control these risks. Hazardous substances include:

• chemicals and products containing chemicals

• dusts

• vapours and mists

• fumes and gases

• biological and infectious agents.

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The EU Regulation on Classification, Labelling and Packaging 2008, has adopted the Global Harmonised System on the classification and labelling of chemicals, which regulates the use of hazard pictograms on the labels of chemical products. These symbols should be considered alongside a product’s safety data sheet when evaluating the hazards and risks of using chemical cleaning and disinfectant products.

Staff involvement

Staff should be involved in developing control measures to make sure they are suitable for the way they carry out the work. Encourage staff to suggest improvements, report anything they think might be going wrong and take action from ‘near-miss’ reports.

Training, instruction and information

Work with staff to ensure they understand the hazards, the risk and the controls properly; ensure they know how to use controls properly, carry out practice drills, can read written information, and understand the language and symbols.

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Health and safety guidance

• COSHH and cleaners - key messages

• COSHH basics

• Working with substances hazardous to health: a brief guide to COSHH

• Control of substances hazardous to health (sixth edition)

Risk assessment

It is the employer’s responsibility to undertake risk assessments of all activities, tasks and procedures carried out by its employees and, if necessary, to take measures to eliminate or reduce risk.

Use a risk-based approach to determine how an area should be cleaned and disinfected, the frequency of the clean, the product to be used and the concentration at which it should be used.

The area should be assessed based on the infection risk and the occupational health and safety risk. Seek a practical balance to protect patients’ and employees’ health.

Carry out a health and safety risk assessment by following these steps in order:

Step Action

1 Accurately identify potential hazards in the work area or task; a hazard is a

potential source of harm or adverse health effect.

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http://www.hse.gov.uk/pubns/books/l5.htm

http://www.hse.gov.uk/pubns/indg136.htm

http://www.hse.gov.uk/coshh/basics.htm

http://www.hse.gov.uk/coshh/industry/cleaning.htm

2 Decide who might be harmed and how.

3 Evaluate the risk and the potential for harm; risk is the likelihood that a person

may be harmed or suffer adverse health effects if exposed to a hazard.

4 Identify and implement controls.

5 Record your findings and implement them.

6 Specific controls should be incorporated into the method statement and into

technical training modules.

7 Frequently review the assessment and update.

Consider vulnerable workers and how the risk assessment may need to be adapted to accommodate their needs. Vulnerable workers include:

• new, expectant and breast-feeding mothers

• young and older workers

• workers with disabilities

• temporary or agency workers

• those new to the job

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• Risk Assessment • Risk assessment - Brief Guide to Controlling Risks in the Workplace • The health and safety toolbox: How to control risks at work • Health and Safety related to Cleaning

Health and safety controls

Risk assessments should determine what control measures are required for each task, in each situation. Control measures should prevent or limit the exposure to hazardous substances for workers, contractors, patients and members of the public, to prevent ill-health. This can be achieved by:

• using control equipment, e.g. total enclosure, partial enclosure, local exhaust ventilation (LEV)

• controlling procedures, e.g. ways of working, supervision and training to reduce exposure, maintenance, examination and testing of control measures

• worker behaviour, making sure employees follow the control measures.

Use the ‘hierarchy of controls’ model to identify the correct controls for a given situation, as illustrated in Figure 2 below.

Figure 2: The hierarchy of controls

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http://www.hse.gov.uk/cleaning/index.htm

http://www.hse.gov.uk/toolbox/index.htm

http://www.hse.gov.uk/pubns/indg163.htm

http://www.hse.gov.uk/cleaning/topics/risk-assessment.htm

Source: Institute of Occupational Health and Safety https://www.iosh.co.uk/Books-and-resources/Our-OH-toolkit/Noise/Noise-control-measures.aspx

The control measures identified by the risk assessment should be incorporated into the method statements (see ‘cleaning operating procedures’, page 64) and into the technical and health and safety training modules.

Personal protective equipment

The issue and use of personal protective equipment are governed by the Personal Protective Equipment Regulations 2002 and the Personal Protective Equipment at Work Regulations 1992 (as amended).

Personal protective equipment (PPE) is equipment that will protect the user against health or safety risks at work. It can include items such as safety helmets, gloves, eye protection, high-visibility and protective clothing, safety footwear and safety harnesses. It also includes respiratory protective equipment (RPE).

PPE should be used when all other measures are inadequate to control exposure. It protects only the wearer and only while being worn correctly. If PPE is still needed after implementing other controls, employers are responsible for providing, replacing and paying for PPE. Employees must follow procedures and safe systems of work and use equipment as they have been trained, including using PPE provided by the employer.

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https://www.iosh.co.uk/Books-and-resources/Our-OH-toolkit/Noise/Noise-control-measures.aspx

Equipment must be chosen carefully; ensure that employees are trained to use it properly and know how to detect and report any faults.

Points to consider for selection and use of PPE

• Who is exposed?

• What are they exposed to?

• How long are they exposed for?

• How much are they exposed to?

• Choose products which are certification (CE) marked in accordance with the Personal Protective Equipment Regulations 2002 – suppliers can advise

• Choose equipment that suits the user – consider the size, fit and weight of the PPE

• If more than one item of PPE is worn at the same time, make sure they can be used together, e.g. wearing safety glasses may disturb the seal of a respirator, causing air leaks

• Instruct and train people how to use it, e.g. train people to remove gloves without contaminating their skin. Tell them why it is needed, when to use it and what its limitations are

• PPE must be properly looked after and stored when not in use, e.g. in a dry, clean cupboard. If it is reusable it must be cleaned and kept in good condition

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• Personal Protective Equipment

• INDG174 Personal Protective Equipment at work

Appendix 1 contains more detailed information on key health and safety topics that relate to cleaning and disinfection activities. These ‘key topics’ can also be accessed through icon links within the cleaning operating procedures (COP) posters located in the COP manual; see Appendix 7 for examples.

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http://www.hse.gov.uk/pubns/indg174.pdf

http://www.hse.gov.uk/toolbox/ppe.htm

Cleaning responsibilities framework

Healthcare establishments have varying shapes, sizes and ranges of equipment, both clinical and non-clinical, which require cleaning. Responsibility for cleaning can also vary and will include, at least, cleaning services providers, nursing and other clinical and non-clinical staff (including housekeepers) and estates staff.

Assigning responsibility for specific cleaning functions is a significant and essential task. Cleaning experts’ experience suggests there is considerable opportunity for items such as equipment to ‘fall through the gaps’. For this reason, local cleaning responsibility frameworks must be agreed using a multidisciplinary team approach, including frontline workers from both clinical and non-clinical teams. This will ensure that all items that require cleaning are captured.

Appendix 2 lists clinical and non-clinical items that require cleaning, across 50 elements grouped under broad headings. Taken together, these will cover most items and areas to be cleaned in healthcare environments. However, within these broad headings is a much greater range of specific items for which a national list is not appropriate. Healthcare establishments must therefore produce a local schedule of cleaning responsibilities specifically detailing all items to be cleaned and who is responsible for cleaning each item. It is essential to allow enough time and training to carry out specific cleaning tasks, regardless of the team member assigned to the task.

Appendix 6 is an example of a cleaning responsibility framework with suggested cleaning frequencies and responsibilities to meet safe standards. Ensuring that responsibilities are clear, and whole items are cleaned in one process by one individual and/or staff group, will help compliance.

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Safe cleaning frequenciesDiscussions with NHS cleaning service providers suggests that a single national version of safe cleaning frequencies is inappropriate since it cannot meet every healthcare organisation’s needs. It would also stifle the ability of healthcare organisations to allocate cleaning resources where they are most needed, and potentially compromise the requirement to give more control to clinical teams in terms of agreeing where available cleaning services are best deployed.

However, the safe cleaning frequencies detailed in Appendix 2 are a required baseline for healthcare organisations. The frequencies are based on subject matter expert knowledge and supporting policies and procedures contained in the reference section of this document.

If healthcare organisations choose to produce an enhanced frequency schedule or a blended approach there must be a clear written rationale, risk assessment, and supporting local safe cleaning frequency schedule.

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General Principles of Cleaning and DisinfectionThis section outlines the general principles of the cleaning operating procedures i.e. detailed methodologies for cleaning or cleaning and disinfecting in a healthcare environment. It is impractical to list all items or areas to be addressed so it is important that the principles behind effective cleaning and disinfection are understood so that they can be applied when confronted with cleaning tasks or equipment not specified in the cleaning operating procedures document.

Definitions

The terms cleaning, disinfection, decontamination and sterilisation are often used interchangeably but they are different and it’s important to understand the difference in a healthcare environment where ‘cleaning’ in patient care environments

Cleaning - Cleaning involves ‘fluid’ -usually detergent and water – and ‘friction’ the mechanical or physical removal of organic matter including dirt, debris, blood and bodily fluids. Microorganisms are removed rather than killed.

Whilst cleaning alone may be sufficient in areas such as foyers, offices, corridors and other ‘low risk’ environments, the addition of disinfection to cleaning is more appropriate in many healthcare environments.

Cleaning alone will leave a surface or equipment visibly clean if carried out effectively. Cleaning is an essential pre-requisite to effective disinfection. Disinfectants, some more than others, are readily deactivated in the presence of organic matter.

Disinfection - Disinfection is the process of eliminating or reducing harmful microorganisms from inanimate objects and surfaces.

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‘Cleaning’ within a healthcare / clinical environment e.g. in higher risk areas usually involves increased cleaning frequencies and the use of a disinfectant to protect vulnerable patients.

Assessment of cleanliness by visual inspection alone may not provide adequate assurance that the number of potentially harmful microorganisms in the environment have been reduced to a sufficient level to provide a safe environment of care and more objective methods of assessing cleanliness should be considered.

Sterilisation - Sterilisation is the process of killing all microorganisms and is achieved through physical or chemical means and is not a process used in the context of environmental decontamination. Sterilisation is used for critical items i.e. objects or instruments that enter or penetrate sterile tissues, cavities or the bloodstream that can cause a high risk of infection if contamination takes place with any microorganism.

Decontamination - Cleaning, disinfection and sterilisation are all decontamination processes. In the context of decontamination of the environment or non-critical equipment (i.e. equipment or devices that are in contact with intact skin) the term is usually applied to a combination of cleaning and disinfection either as a two-stage process i.e. the use of a separate cleaning and disinfecting agent or a ‘2 in 1’ product that cleans and disinfects in one step.

Choice of cleaning / disinfecting agent

Local policy should outline where and when detergent and water alone are sufficient and where a detergent and disinfectant (or combined cleaning and disinfecting agent) is required.

Staff should familiarise themselves with the local policy and how to make up any cleaning / disinfecting solutions in line with manufacturers’ instructions. Staff should be trained in how to prepare any disinfectants safely in a well-ventilated area using the appropriate PPE. They should also be aware of how to store unused product and how to dispose of it safely.

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Contact time

A disinfectant will need time in contact with a surface to allow it to work. Staff should be aware of the contact times of the disinfectants in use locally. The surface should remain wet long enough for the contact time to be achieved and realistic contact times for use in a busy healthcare environment should be a consideration when selecting products for use.

Direction of cleaning

To minimise recontamination of an area and transfer of microorganisms, clean from

top to bottom

clean to dirty

When dusting horizontal surfaces in a patient room, high areas such as those above shoulder height should be done first followed by all other elements. Dusting technique should not disperse the dust, (i.e. use damp cloths/dusting devices).

Floor cleaning should be completed last when cleaning a defined area. It is important to place adequate signage when floor cleaning is in progress to prevent slips, trips and falls on wet floors. It is important to remember that all floor signage should be removed as they are a trip hazard once the floor is totally dry.

Manual cleaning action

Clean large and flat surfaces using an ‘S’ shape motion, starting at the point furthest away from you, overlapping slightly and without going back over the area to avoid recontamination.

Frequent touch surfaces

Frequent touch surfaces in patient care and procedural areas, such as door handles, call bells, light switches, cot sides etc. should be cleaned more frequently than surfaces with minimal hand contact.

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Transference

Cleaning solutions can become contaminated during use and continued use of a contaminated solution may transfer microorganisms to each subsequent surface being cleaned. Therefore, cleaning solutions should be regularly replaced in accordance with the manufacturer’s instructions and more frequently when cleaning heavily soiled areas; when solutions appear visibly dirty and immediately after cleaning blood and body fluid spills e.g. when using a socket mop.

Microorganisms can also be transferred between surfaces on cleaning cloths and wipes as well as hands. To minimise the risk of cross contamination:

• when using a cloth and bucket do not ‘double dip’ used cloths into the bucket containing cleaning solution or into the container of unused, pre-soaked clean cloths

• cleaning cloths such as microfibre cloths should be folded and rotated in a manner to utilise all surface areas of the cloth, including the front and back, and used in such a way to avoid cross contamination whilst maximising efficiency. Staff should be trained how to fold and use the cloth effectively and safely

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• when using pre-impregnated disposable wipes the general principle is ‘one wipe, one surface’. Using one wipe at a time ensures that a flat wipe covers an optimal surface area depositing the correct amount of detergent/disinfectant on the surface being decontaminated; maximises the use of all of the wipe surface; minimises the risk of transfer of microorganisms and is more cost effective. Some procedures will require more than one wipe and they should be disposed of once visibly soiled and between different surfaces/pieces of equipment

‘Don’t buy it if you can’t clean it’

Due consideration should be given to how equipment, medical devices and surfaces are to be decontaminated before they are purchased rather than afterwards.

Manufacturers can provide on request clear and appropriate instructions with regard to cleaning and disinfection. If necessary, advice should be sought from the infection control team when purchasing equipment or medical devices, or during a new build or refurbishment projects.

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Risk categories and standards for functional areasPurpose

All healthcare environments should pose minimal risk to patients, staff and visitors. However, it is important to recognise that different functional areas represent different degrees of risk and, therefore, require different cleaning frequencies and levels of monitoring and auditing. For example, a records storeroom, not used by those at high risk of infection or who themselves constitute a high risk of cross-contamination, will require less cleaning than an intensive care unit (ICU).

Consequently, all functional areas must be assessed and assigned one of the six Functional Risk categories detailed within this section.

The table below outlines the functional risk and associated audit target scores:

Functional risk category Audit target score

FR1 98%

FR2 95%

FR3 90%

FR4 85%

FR5 80%

FR6 75%

Identifying the functional risk category is the crucial first step in applying the standards: the level of cleaning frequency, monitoring, audit frequency and audit target scores are all directly linked to the identified risk factor.

It is not mandatory for healthcare organisations to adopt each functional risk category, for example, an organisation may choose to use: FR1 98%; FR2 95%;

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FR4 85%; and FR6 75%, or any other combination. However, a decision not to adopt all six risk categories should not dilute achieving safe standards in individual or collective functional areas. Healthcare organisations must therefore have a sound written rationale for deciding to use a different approach (see governance for functional risk areas). Adoption of all six functional risk categories is considered good practice.

These standards include a template guide (below) to which functional areas might be allocated within each functional risk category, but ultimately risk identification is a decision to be made locally since no two organisations are the same. As a guide, organisations can use the relevant functional risk audit score and cleaning frequency to help determine which areas qualify for which category.

Functional risk (FR) categories

You can adopt or localise the template guide below on functional risk category allocation.

We recommend that communal areas (i.e. patients and corridors and public toilets) directly associated with all the areas listed under each functional risk below should be categorised as the same FR level.

Functional risk 1 (FR1)Audit target = 98% and aboveAudit frequency = weekly

Suggested categories for functional areas

Intensive care units

Operating theatres

Chemotherapy/immunocompromised units

A&E/resus/minor injuries/major trauma

Delivery suites

Augmented care

Pharmacy aseptic

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Functional risk 2 (FR2)Audit target = 95% - 97%Audit frequency = monthly


Acute and Community Wards

Treatment rooms where invasive procedures take place

Endoscopy units

Cardiology intervention suites

Cardiac catheterisation units

Sterile services units

X-ray (interventional)

Dialysis units

Functional risk 3 (FR3)Audit target = 90% - 94%Audit frequency = bi-monthly


Mental Health and Learning Disabilities Wards

Urgent care centres

Dental outpatient departments

Sexual health (GUM) clinics

Mortuary

Emergency patient transport vehicles (ambulance/air ambulance)

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Functional risk 4 (FR4)Audit target = 85% - 89%Audit frequency = quarterly


Treatment rooms where invasive procedures do not take place

X-ray (non-invasive) /MRI/CT rooms

136 suite/seclusion/place of safety rooms

Entrances, receptions and public corridors

Waiting areas

Consulting/therapy rooms

Departure/discharge lounges

Rehabilitation units and day centres

Pharmacies

Pathology

Laboratories

General outpatient departments/clinics

Physio outpatient departments

Fracture clinics

Occupational therapy

Audiology

Preop assessment units

Ward/department laundry areas (not central laundry)

Occupational health

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Functional risk 5 (FR5)Audit target = 80% - 84%Audit frequency = six-monthly


Linen and laundry departments

Electrical and biomedical engineering/medical physics

Chapel/prayer rooms

Family/visiting rooms where not directly associated to a ward/department on this list

Main receptions

Non-emergency patient transport vehicles

Functional risk 6 (FR6)Audit target = 75% - 79%Audit frequency = annually


Administration/offices

Medical records

Education/postgrad and training centres

Stores department, with the exception of catering, which is covered by the catering teams

Cleaning specifications – elements, cleaning frequencies and performance parameters

Once an organisation has identified its functional area risk categories, it must produce a ‘cleaning specification’ with more detailed information on how cleaning will take place. This specification should include:

• cleaning elements – a list of individual items/categories of items that require cleaning

• performance parameter – the expected standard of each item (element) once cleaning has been completed

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• cleaning frequency – how often each item (element) should be cleaned, broken down by the functional risk categories.

Organisations may also include information on who is responsible for cleaning each item (element) on the specification. However, this should be in addition to, and not instead of, developing a cleaning responsibilities framework.

It is essential that the frequency of cleaning is broken down by functional risk category in the cleaning specification. In the same way that functional areas need to be divided according to risk, individual cleaning elements will almost always require a different frequency of cleaning depending on the risk category they fall within. For instance, a toilet in an accident and emergency department will require higher frequency of cleaning than a toilet in a low traffic admin area.

Appendix 2 shows an example cleaning specification, which can be localised or used as a template. Organisations do not have to adopt the format of this template, however any alternative used must provide the same key information detailed in this section. The frequencies outlined in the example specification are based on what are regarded as the safe standards required to meet the performance parameters and achieve cleaning audit target scores. It is important to note that the example specification is a guide only, because a single national approach would be unlikely to meet the needs of every healthcare organisation and location. But we recommend that the cleaning frequency in the example specification must not be reduced below the safe standard levels suggested when localising.

The example cleaning specification uses the 50 cleaning elements most commonly found in healthcare settings, but the list is not intended to be exhaustive. Healthcare organisations may add items to the specification but should consider that the same 50 elements are used for the auditing section, so they should identify where these items sit within the 50 elements for auditing. For example, an organisation may create a separate element on the specification for picture frames but for auditing purposes will consider it under ‘high dusting’. Additionally, any elements added should be reflected in an organisation’s cleaning responsibility framework.

When developing a cleaning specification, organisations should decide on frequency based on infection prevention and control risks but also consider patient/public confidence and aesthetics. A floor in a public corridor would not

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generally be considered a high infection prevention and control risk, but its standard of cleanliness significantly impacts on confidence.

Cleaning frequency definitions

In order to make best use of resource and meet all requirements, we strongly recommend that organisations differentiate between types of cleaning in cleaning specifications. For instance, it may not be necessary to always undertake an additional daily clean of many items, but it may be important to validate this, which is the intention of a ‘check clean’. You should use these three routine cleaning frequency definitions:

• Full clean – cleaning all elements using an appropriate method to remove all visible dust, dirt, marks and contamination, leaving the item in accordance with the required performance parameters.

• Spot clean – cleaning specific elements using an appropriate method to remove all visible dust, dirt, marks and contamination, leaving the item in accordance with the required performance parameters.

• Check clean – a check to assess if an element meets the performance parameter standard of the full clean to identify if an additional clean is required. If it does not meet the standard, a full clean or a spot clean should be undertaken (in line with the above) to bring the element up to the performance parameter level.

• Periodic clean – full clean of an item carried out at a set interval as part of routine environmental maintenance where daily or weekly activity is not required. This by definition becomes periodic (fortnightly, monthly – four weeks), quarterly (12 weeks), six-monthly or annually. Periodic cleaning items that are beyond fortnightly or monthly frequency, and are therefore not routine (i.e. carpet washing, floor stripping/polish/sealing and external window cleaning), should form part of a planned and documented annual programme.

• Touch point clean – a full clean of items that are frequently touched as identified in the frequent touch point section below using an appropriate method to remove contamination.

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Enhanced cleaning

The above frequencies and frequency definition guidance are based on routine service provision. Organisations should recognise as part of their planning process that events may alter the resources their cleaning service requires – for example, in managing infection prevention and control cleaning and outbreaks.

Cleaning planning should clearly identify and document the specific additional steps required before, during and after a full clean related to these circumstances. These additional steps should be identified by organisations based on local infection prevention and control policy and advice, in line with national guidance and good practice.

High frequency touch points

It is widely recognised that hand-mediated transmission is a major contributing factor in the acquisition and spread of infection within healthcare environments. It is therefore essential that cleaning plans recognise the importance of environmental elements that are frequently touched by hands, to help minimise the risk of organism transfer between individuals and surfaces.

When developing cleaning specifications, organisations should particularly consider elements that are high frequency touch points. Cleaning frequencies should be adjusted accordingly: this can be done by focusing on the specific high-risk parts of that element (i.e. cleaning the door handle more frequently than the door).

Examples of high frequency touch points are listed below, but this is not an exhaustive list and each organisation should make its own assessment depending on the area and service delivered. The example cleaning specification in Appendix 2 includes weighting towards high frequency touch points.

Wards and departments:

• light switches/plastic pulls

• taps, dispensers, toilet flush handles

• door handles and push plates

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• over-bed table and trays

• bed rails

• grab rails

• patient chair arms and seat

• relevant parts of notes, linen, drug and general purpose trolleys

• nurse call buttons

• TV remote control

• bedside drawers and locker handles

• kitchen cupboard handles

• patient entertainment system, including any TV remote controls

• patient area multi-user phones and computer buttons and receivers

• fridge and freezer handles

• ice machines, hot water boiler and cold-water machine buttons/levers

• cooker and microwave handles and buttons.

Public areas:

• elevator plates and call buttons

• light switches/plastic pulls

• door handles and push plates – all areas

• grab rails

• taps, toilet flush handles, dispensers and hand dryers in public toilets

• chair arms and chair seat in waiting areas.

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Note that the list above is focused on environmental cleaning and is not intended to capture items (i.e. patient equipment) that require cleaning between use, e.g. blood pressure cuffs. For a full list of items that require cleaning between patient use, please refer to local protocols/policies.

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Auditing and monitoring informationPurpose

It is important to provide assurance at all levels that healthcare organisations are meeting safe standards of cleanliness in their establishments, and that they can demonstrate to patients, public and staff that cleanliness meets the required standards. This supports infection prevention and control good practice by making patients, staff and the public confident that both the outcomes and efficacy of cleaning are safe.

The auditing system should work in all types of healthcare setting and provide clear evidence that cleanliness standards are being met safely and responsibly. It should also detail any service deficiencies and areas for improvement.

Principles

The audit principles for the national standards of healthcare cleanliness are intended to provide a universal approach to auditing healthcare cleanliness in all types of healthcare settings. The overarching aim is to encourage safe standards of cleanliness in all healthcare environments. The audit process is designed to be easy to use and adaptable to local requirements by being flexible and therefore future proof.

Cleaning and infection prevention are intrinsically linked. It is therefore essential to audit both the outcome of cleaning and the process by which the cleaning standards are achieved to demonstrate the efficacy of cleanliness. To meet safe standards, the efficacy of the cleaning process is as important as the technical outcomes of cleaning, which is why it is now an area of focus.

Delivering cleanliness that provides assurance is critical, and therefore displaying more transparent results is now a fundamental part of the audit process.

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The acronym EFFECT captures the audit principles in terms of effecting positive change to achieve the results required, which are ultimately safe standards of cleanliness:

• Easy to use

• Flexible

• Future proof

• Efficacy of the cleaning process i

• Cleanliness that provides assurance

• Transparent results.

Audit risk categories and standards

As described in the earlier section, ‘Risk categories and standards for functional areas’ (see page 29), the audit standard operates according to six functional risk categories and six target audit scores, within which each cleanable clinical and non-clinical functional area in a healthcare facility is allocated, summarised below:

Allocating functional risk categories is a crucial first step in applying the standards since the level of monitoring and audit is directly linked to the identified risk factor.

Audit scores

The audit scores for each functional area will be represented in two ways: a percentage score and a star-rating score. The percentage score is intended for internal verification and scrutiny of the safe standard achieved, whereas the star-rating score is intended for external verification of the safe standard achieved.

The purpose of this approach is to provide a more easily recognisable, accessible, and easy-to-understand system for patients, the public and staff, as star-rating systems are already widely used in many other industries such as hotels, restaurants and media. Star rating is also used successfully by professional organisations, such as the food safety ratings for food premises (Scores on the Doors).

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Percentage score

There are six functional risk categories with six corresponding target percentage scores, detailed below and described in ‘risk categories and standards for functional areas’.

Functional risk category Audit target score

FR1 98% and above

FR2 95% and above

FR3 90% and above

FR4 85% and above

FR5 80% and above

FR6 75% and above

FR1

The target score is 98% and above. Guidance in the risk categories section shows which functional areas may fall into FR1.

FR2


FR3


FR4


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FR5


FR6


Other options

Not adopting all functional risk categories

Healthcare organisations may choose not to adopt each functional risk category, for example, an organisation may choose to use FR1 98%; FR2 95%; FR4 85%; and FR6 75%, or any other combination. However, a decision not to adopt all six risk categories should not dilute efforts to achieve safe standards in individual or collective functional areas. Organisations must therefore have a sound written rationale for deciding to use a different approach (see governance for functional risk areas). Adopting all six functional risk categories allows for the smooth transition from the National Specifications for Cleanliness in the NHS 2007 and provides the flexibility that has often been sought after for different healthcare environments.

Blended area option

Within each functional risk area, it is possible to allocate different risk categories to individual rooms. This means that rooms within functional risk areas could be risk assessed according to activity and allocated different target scores: for example, an office or a meeting room could be categorised as FR5, a staff room as FR3, and an inpatient room as FR2.

Using this approach means that different types of room within a functional area are cleaned and audited according to their risk category. This methodology may also facilitate the better use of resources.

If this approach is adopted, it is important to note the activity: for example, if clinical staff are using an office in a clinical area, it is likely the office should be cleaned to the same frequency as the remainder of the functional area. It is important to

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determine the risk each area poses and make a pragmatic decision based on these risks.

The proportion of areas in each risk category within a functional area will determine the overall functional area risk assessment, and a new overall target score can be calculated: see examples 1 and 2 below. After this evaluation, it is important to determine what the auditing frequency should be for blended areas.

The ‘Audit process’ section (see page 50) provides full guidance on the recommended audit frequencies for each of the six functional risk categories. However, organisations can adopt many approaches to determine the audit frequency for blended areas based on risk and practicality.

In Example 1 below there is one room in FR2 that represents 8% of the overall area. It could be decided that the overall area is therefore audited quarterly; alternatively, an organisation may decide to audit the FR2 room monthly and the remaining area quarterly. Example 2 shows 75% of the rooms falling into FR2. In this instance, the likely outcome is that the area is audited monthly.

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Example 1: Outpatient area

This is an outpatient area that has a mix of rooms, including a minor operations suite that would be higher risk, as detailed below:

Risk category Functional area score

Number of rooms Calculation

FR 2 95% 1 1 x 95 = 95

FR 4 85% 10 10 x 85 = 850

FR 5 70% 1 1 x 70 = 70

Total 12 95 + 850 + 70/12 = 84.58%

The overall category would be Blended Functional Risk Area: FR2/4/5 – 84.58%Audit frequency options: quarterly whole area, or audit the FR2 room on a monthly basis* and the remaining area on a quarterly basis

The overall category is Blended Functional Risk Area: FR2/4/5 with a target score of 84.58% and audit frequency determined by the healthcare organisation according to risk and practicality.

* Please refer to the section headed: technical audit sample size: ‘in small areas with 10 or fewer rooms then is it good practice for 100% of these rooms to be audited at the same time’, please note if one room is classed as a functional risk area in isolation this will not provide an accurate cross section and reflection of the quality of cleanliness with the healthcare organisation.

Example 2: General inpatient ward

This is a general inpatient ward with a mix of rooms.

Risk category Functional area score

Number of rooms

Calculation

FR 2 95% 15 15 x 95 = 1425

FR 3 90% 3 3 x 90 = 270

FR 4 85% 2 2 x 85 = 170

Total 20 1425 + 270 + 170/20 = 93.25%

The overall category would be Blended Functional Risk Area: FR 2/3/4 – 93.25%Audit frequency options: monthly whole area

The overall category is Blended Functional Risk Area:FR2/3/4 with a target score of 93.25% and audit frequency determined by the healthcare organisation according to risk and practicality.

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The functional areas in examples 1 and 2 would be re-categorised as ‘Blended Functional Risk Area’ (FRB).

The functional risk category is a blended area would be a combination of FR1/2/3/4/5/6, depending on the individual assessment of each area. The target audit score and audit frequency would also be determined locally when using this approach as outlined in the table below:

Functional risk category Audit target score Audit frequency*

FR1 98% and above Weekly

FR2 95% and above Monthly

FR3 90% and above Bi-monthly

FR4 85% and above Quarterly

FR5 80% and above Six-monthly

FR6 75% and above Annually

FRBBlended FR risk category determined locally



*See the ‘Audit process’ section (page 50) for recommended audit frequencies.

Governance for functional risk areasThe ‘Risk Categories and Standards for Functional Areas’ section contains clear guidance on the allocation of functional risk categories. Healthcare organisations also have the flexibility to adopt a blended area approach for functional risk areas if they believe this more appropriately meets their specific needs.

The allocation of functional risk categories is a crucial first step in applying the standards since the level of audit is directly linked to the identified risk factor. For this reason, whether the six functional risk categories are used, or the blended area methodology is adopted, healthcare organisations must ensure there is clear documentation outlining the allocation process that has been followed as indicated below:

A written rationale for how the risk category has been derived for each functional area, or room / group of rooms if blended.

A regular review of the functional area, (at least annually, or if there is a significant change in clinical activity), to ensure that the rationale and risk ratings are still appropriate.

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A written record of the functional area review as described in point 2 above.

Star-rating scoreStar ratings are a simple and effective means of providing meaningful information about quality (see Figure 3 on page 48). The star-rating system is intended to provide patients, public and staff with an easily understandable visual score of the safe standard of cleanliness for each functional area.

The star-rating system aims to provide reassurance to patients so you should decide locally where to display the star ratings – and where not to display them. We recommend they are only displayed in patient-facing areas; it is not necessary to display star ratings in functional risk areas where inpatients or outpatients do not go. There may be instances where organisations deem it impractical to use the star ratings – for example, in ambulances or in community settings with numerous outbuildings, small units, clinics and surgeries.

When agreeing where to display the star ratings, consider disparate sites, type of healthcare setting and the logistics of managing the administration associated with this process. When implemented and used in the correct way, star ratings will reassure patients, the public, departmental and clinical leads.

The star rating must be the actual first-time percentage score achieved converted into a star rating using the recommended guidance detailed in the table below.

The star-rating categories are:

• 5 stars meets or exceeds the required standard

• 4 stars a satisfactory standard has been met

• 3 stars the standard is below expectation and an improvement plan is in place

• 0 stars the standard is significantly below expectation however appropriate action is being taken and an improvement plan is in place

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Audit target score

Functional risk category

Actual sore Star rating

98% FR1 98% or above 5 star – meets or exceeds the required standard

98% FR1 97% - 92% 4 star – a satisfactory standard has been met

98% FR1 91% - 86% 3 star – the standard is below expectation however appropriate action is being taken and an improvement plan is in place

98% FR1 85% or below 0 star – the standard is significantly below expectation however appropriate action is being taken and an improvement plan is in place











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Audit target score Functional risk category

Actual sore Star rating

Determined locally FRB At target or above 5 star – meets or exceeds the required standard

Determined locally FRB 1% - 6% below target 4 star – a satisfactory standard has been met

Determined locally FRB 7% - 12% below target 3 star – the standard is below expectation however appropriate action is being taken and an improvement plan is in place

Determined locally FRB 13% below target 0 star – the standard is significantly below expectation however appropriate action is being taken and an improvement plan is in place

Figure 3: Star-rating displays

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The star ratings must be displayed in accessible areas for visibility, for example, in or near ward and department entrances, outside lift areas for public and circulation areas, or in waiting rooms etc. as appropriate. We recommend that the star ratings are displayed in the same location as the Commitment to Cleanliness Charter.

The frequency of audit will determine how often the star ratings are updated and displayed: for example, an FR1 area is audited weekly and the star rating will therefore be updated weekly.

We recommend that each time a functional area is audited, the star rating is updated and published to assure the public, patients and staff that consistent safe standards of cleanliness are being achieved.

If a functional area has been categorised as a blended functional risk area (FRB), the audit frequency will be determined locally as described in the percentage score section (see page 41), which will inform the frequency of star-rating updates.The star-rating system allows for all functional areas to achieve a five-star rating as follows:

• FR1 target audit score 98% and above is 5 stars






• FRB (blended functional area) – target audit score determined locally.

This approach is intended to encourage staff engagement, improve recognition and enhance the profile of cleaning because all areas can achieve five stars, assuring patients, public and staff that safe standards are being achieved.

It is essential that every audit that falls below standard is rectified in an appropriate timeframe. Any star-rating score below 4 stars must be subject to an improvement plan with agreed timescales appropriate to the functional area and the score achieved.

Functional areas achieving a 5 star-rating, or 4 star-rating are also likely to generate remedial actions to improve (unless they score 100%). In these instances, the

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activity generated through rectification will serve to enhance the focus on the functional area and provide assurance.

Where functional areas have scored 5 stars or 4 stars it is good practice to check that rectifications have been satisfactorily completed in a timely manner before the next scheduled audit. However, where a functional area has scored 3 stars or 0 it will be necessary to undertake a re-audit to provide assurance that the area has now achieved the safe standard. Once the standard has been achieved a revised star rating can be displayed.

The following star-rating escalation flow-chart details the actions that must be taken following each audit of a functional area.

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Star-Rating Escalation Flowchart

All areas under automatic review are subject to an improvement plan. An improvement plan should consider the following:

• An analysis of the failed elements • A review of the cleaning input hours to determine if the resources are

adequate or if there have been staff shortages• A review of cleaning times to determine if the service is being delivered at

the right time• A review of the area to understand if there is a significant change in use• A review of the cleaning times to ensure they reflect the service required• A review of the cleaning frequencies to determine if they are appropriate• Is the equipment, materials and consumables suitable, of adequate supply

etc.• Has appropriate training been undertaken?• Is there a staff competency issue?• Has an efficacy audit been undertaken in the last 12 months?• Has the area risk rating been reviewed and checked?

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Area has achieved its target score or above Rectification of failures is signed off and retained

1% to 6% below five stars Rectification of failures is signed off and retained

7% to 12% below five stars Area placed under review Improvement plan in place

13% or more below five stars Area placed under investigation Improvement plan in place Action taken as appropriate

5

4

3

0

Automatically under review

• Has a temporary increase in monitoring been considered until standards have been consistently met and maintained?

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Audit processThe intention of the audit process is to drive safe standards in all healthcare environments, whether a cleaning service is insourced or outsourced. The audit process will ultimately encourage quality improvements and should not be punitive.

There are three stages to the audit process:

1. technical audit that checks and scores cleanliness outcomes against the safe standard

2. efficacy audit that checks the cleaning team at the point of service delivery to validate the efficacy of the cleaning process, i.e. the correct use of colour coding, equipment, materials, methodology, etc as well as supporting policies and procedures

3. external audit to provide quality assurance and to check both the technical audit and the efficacy audit.

Technical audit methodology and frequency

Technical audits

These are regular audits undertaken by appropriately qualified staff that form a continuous and inseparable part of the day-to-day management and supervision of cleaning services.

Timing of technical audits

We recommend that, wherever possible, technical audits take place as soon after cleaning as practical. Technical audits should also consider the frequency of cleaning and the time the cleaning is scheduled to take place.

Regular reviews should take place to understand if the time or frequency of cleaning and associated risk category need to be adjusted to continuously improve safe cleaning standards.

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Auditors need to exercise discretion in judging the acceptability of any element. For example, one or two scuff marks on a floor, an isolated smudge on a window, or a hand towel/tissue dropped on a floor in an otherwise clean area, should not indicate that the element is scored as unacceptable, (see ‘Technical audit protocols’, below).

Multidisciplinary teams

It is good practice to adopt a multidisciplinary approach to technical auditing periodically, to assess the cleaning from different perspectives. The team should include both those responsible for delivering the service and those receiving the services – for example, infection prevention teams and nursing staff, as well as service users. The frequency of MDT audits is for each healthcare organisation to decide. The value of auditing collectively with colleagues from other disciplines cannot be underestimated and will add value to the audit process and overall outcomes.

Audit personnel

Audits (particularly technical audits) should not be the sole responsibility of the cleaning services department. The task should be shared among all the relevant stakeholders in the healthcare facility.

Managers and staff involved with audits should:

• have a detailed knowledge of healthcare establishments and procedures and the service level agreements in place

• be professionally competent to judge what is ‘acceptable’ in terms of cleanliness and infection prevention and control (local protocols and agreements should provide help to support this)

• be able to make discriminating judgements on risk relating to the areas being cleaned and any associated risks relating to individual elements or items

• be able to make informed judgements on the extent to which existing cleaning frequencies may be insufficient

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Technical audit protocols

It is important that organisations agree the principles against which they audit and how to score each element in terms of what constitutes a pass and what constitutes a fail. The table below identifies some scenarios that may occur during technical auditing, with suggested model responses. It is good practice to work through these scenarios and agree the specific standards that technical auditors will adopt. Undertaking this exercise will ensure the audit process is consistent, regardless of who is undertaking the audit.

We recommend healthcare organisations undertake a review of the scenarios listed below and agree their response, which may be the same as the suggested model guidance. The agreed organisation response should be detailed against each scenario if different from the suggested guidance and scenarios added or deleted as applicable.

No Technical audit – clarity/understanding

Suggested model guidance

Organisation agreed process

1 Do all staff carrying out the audit agree on the process and criteria for audit at the beginning of audit?

Yes

2 When auditing, is consideration given to the time and/or progress of the healthcare cleaning services in the ward/area: i.e. before/after the start of cleaning services?

As soon after cleaning as possible. Where this is not possible, consider the time cleaning was performed.

3 Example: washroom area – all elements clean and evidence of good day-to-day practice.

If there is wet toilet paper on the floor, does that look like a recent event? Would the floor fail? No.

4 Example: six curtains in a bay – all curtains are dated and correctly hanging except one that has one hook missing or recently soiled. Does the curtain element fail?

If the one bed area was inaccessible for cleaning, the area would not fail (however the rectification should be recorded, and action taken on the one curtain that does not meet the standard).

5 Is the auditing schedule and planning undertaken by the stakeholder

The stakeholder responsible for cleaning

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responsible for cleaning? should be involved in the auditing.

6 Wherever possible, are the technical audits carried out by three stakeholders? (Supplier, facilities and nursing)? If there is a difference of opinion, is there scope for a 2 to 1 vote to ensure a judgement is made?

Wherever possible, a consensus should be sought.

7 Is there a review process to validate the technical audits (i.e. infection prevention and control, matron, etc)?

This should form part of the assurance programme.

8 Example: six beds in a bay – five are free from dirt and dust but one has one day’s dust. Do all the beds fail?

If the one bed area was inaccessible for cleaning, the area would not fail.

9 Example: a floor is free from grit and dust but is dull/lacks shine (maybe in high traffic areas). Does the floor fail?

The floor should have a uniform finish in line with the specification and requirements, taking account of dementia requirements.

10 Example: a wall in a side room is visibly clean but has one black scuff mark. Does the wall fail?

This area should not fail.

11 Example: a floor area is clean and free from grit and dust but has two black scuff marks. Does the floor fail?

Consider whether this will affect confidence and decide based on that criterion.

12 Should the hospital be clean 24 hours a day: i.e. same standard at 6am as 3pm (bearing in mind minimum cleaning frequencies as set out in the standards)?

Cons aider the cleaning frequency, area type and elements cleaned.

13 Is there external benchmarking to verify standards – i.e. cross-site and neighbouring healthcare organisation benchmarking?

This is good practice.

14 Example: six windows in a bay – five are clean, but one has a handprint on the glass. Do all windows fail?


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15 Example: 15 patient lockers are clean, but two lockers have sticky tape residue left by clinical staff. Do all lockers fail?


16 Example: towel dispensers – when opened, there is a small amount of white dust inside the unit. Does the dispenser fail?

This area should not fail, but a note should be taken for this area to be cleaned.

17 Example: ward kitchen – the dishwasher is visibly clean, but inside there is some evidence of water scale. Does the dishwasher fail?

This area should not fail, but a note should be taken for it to receive remedial treatment.

18 There are two sticky tape marks on a wall where evidently there was once a sign. This was not noticed on previous audits. Does the wall fail?


19 If an audit is not carried out within the agreed timeframe/frequency (i.e. weekly), will a score of 0% be automatically awarded?

If an audit is not carried out, no score can be given.

20 Example: six beds inspected and four have white lint dust. Do the beds fail?

Revert to the cleaning frequency for the functional area to determine if this is a failure.

21 Is the rectification process clearly defined and consistent – i.e. immediate action or as soon as practically possible only on advice from infection prevention and control?

Rectification will depend on the risk category for the area and the infection prevention and control risk, to be agreed in discussion with IPC and based on the specification.

22 Is the cleaning provider aware more than 24 hours in advance of the audit and location?

The audit locations should not be pre-scheduled and publicised, however the date and time that audits are to be undertaken is likely to be publicised to

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ensure the personnel required to audit are available.

23 Example: small amount of limescale inside the tap spout – is this a fail?

Dependant on the agreed cleaning frequency (this may also initiate a review in line with the healthcare organisation’s water policy).

24 Is equal emphasis placed on nursing and healthcare cleaning items?

Yes, the same emphasis needs to be placed on all items to be cleaned.

Frequency of technical audits

Healthcare organisations have the freedom to decide which audit frequency best meets the requirements for each functional area to monitor safe standards. The frequency of audit should be reviewed regularly to meet the changing needs of the service, patients and the environment, and to continuously improve safe cleaning standards.

As a guide, please see suggested audit frequencies below:

Audit target score Functional risk Audit frequency

98% and above FR1 Weekly

95% and above FR2 Monthly

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90% and above FR3 Bi-monthly

85% and above FR4 Quarterly

80% and above FR5 Six-monthly

75% and above FR6 Annually

FRB – Blended functional area audit frequency to be determined locally

Technical audit sample size

Good practice suggests that a minimum of 50% of each functional area should be audited in one session so the audit is representative of the whole area. This means that if an area has 20 rooms, a minimum of 10 rooms must be audited, including all 50 elements within these 10 rooms as applicable. In small areas with 10 or fewer rooms, it is good practice for all these rooms to be audited at the same time. Auditing at least 50% of each functional area will provide a more accurate cross-section and reflect the quality in the organisation.

Technical audit scoring

The auditor will score elements according to the standard for each element, either pass (score 1) or fail (score 0) room by room. This will build up the score for each functional area (see section relating to elements, page 33).

The scoring will reflect the assigned general responsibility for elements as determined by each healthcare facility as advised in the cleaning responsibilities section (see page 28). The four assigned areas are cleaning, nursing, estates or other services.

The electronic version of the score sheet will calculate the percentage score achieved for each functional area. An example of a completed audit score sheet is shown in Appendix 4.

The score sheet allows for calculations to be made horizontally (outcome per room) and vertically (outcome per element) along with the totals referred to above.

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Where an element fails and is scored as 0, the reason for failure needs to be assigned using a standard failure list. The appropriate time for remedial action has been determined using the rectification table.

Once all elements in the room have been scored, the total number of pass scores should be expressed as a percentage of the total possible number of ‘pass’ scores in that room. For example, if the sanitary area had a maximum of 12 elements, and 10 passed, the overall percentage would be calculated as 10/12 or 83.33%.

The functional area score is calculated by taking the total number of pass scores expressed as a percentage of the total possible number of pass scores in the functional area. In this example it is 128/134 = 95.30%.

Functional area Room Total questions Audit questions passed

Audit score

FR1 1 35 34 97.14%

FR1 2 40 39 97.5%

FR1 3 44 44 100%

FR1 4 25 25 100%

FR1 5 21 20 95.24%

FR1 6 15 15 100%

Total 180 177 98.33%

Overall target score

Once healthcare organisations have determined their target scores in each risk category, an overall target score can be calculated by determining the percentage of the hospital or other type of premises that falls into each risk category.

The overall healthcare facility score is then calculated by taking the total number of pass scores expressed as a percentage of the total possible number of pass scores in the healthcare facility. In this example it is 7,700/8,930 = 86.23%.

Functional, building or Number Calculation Maximum Actual

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facility score of areas score score

FR1 98% 10 10 x 98% 980 900

FR2 95% 40 40 x 95% 3,800 3,500

FR3 90% 15 15 x 90% 1,275 1,025

FR4 85% 20 20 x 85% 1,700 1,400

FR5 80% 10 10 x 80% 800 600

FR6 75% 5 5 x 75% 375 275

Total 100 8,930 8,930 7,700

Maximum target score for the whole facility

89.30% 86.23%

Where an overall score is required, or there is a need to group facilities, an aggregated score can be used to form the overall score for cleanliness. However, you must take account of the relative size of each of the healthcare facilities being aggregated. Healthcare providers need to determine the configuration of their sites and how they want the reports to be generated.

Timeframe for rectifying technical problems

Regular audits should form part of the cleaning services and quality assurance programme. Issues raised should be followed up according to their magnitude and location. Lead times should be identified for remedial action. For example, a problem in an operating theatre will need to be resolved within one hour of the audit, while one in a stationery storeroom will need to be resolved within a week or during the next scheduled audit.

The table below can be used to measure the rectification requirements of cleaning each element in any functional area. For example, a toilet in an operating theatre and a toilet in a waiting room should be equally clean. However, the floor of a maintenance workshop requires less attention than the floor in an ITU/ICU.

Any urgent issues found during the audit will need to be flagged and rectified immediately either by the auditor or by escalation through operational teams, eg empty soap dispensers, bodily fluids requiring removal, health and safety, and infection prevention and control issues.

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All routine failures picked up during the audit should be rectified according to documented local agreement. The table below provides guidelines for recommended maximum timeframes for rectifying cleaning problems.

Priority of rectification Maximum timeframe for rectifying cleaning problems

All areas regardless of functional risk rating where there is a health and safety, patient safety or infection prevention and control issue.

Action to be taken immediately.

Please note that where there is a health and safety, patient safety or infection prevention and control issue, this must represent an immediate risk to patient, public or staff safety, for example, a hazardous spillage, no soap or hand towels, no warning signs displayed.

FR1 Rectified during the next scheduled cleaning service or as agreed at the time of audit






FRB(Blended Functional Area)

Rectified during the next scheduled cleaning service or as agreed at the time of audit

Trend analysis

We recommend you analyse the quality data, including trend analysis, as part of continuous service improvement. Trend analysis will identify specific areas that require review and will help to identify where resources are best deployed.

Technical audit reporting

Cleanliness audit scores can be determined for the same type of equipment or the same element across a whole healthcare facility or parts of buildings. Scores can

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also be broken down further – for example, across all wards or departments, or groupings of wards and departments. This enables you to identify any variations in quality across similar areas and the specific causes of failure you need to address to meet safe standards.

Efficacy audits

The efficacy audit is a management tool to ensure the process of cleaning follows good practice and meets infection prevention guidelines by ensuring correct procedures are consistently delivered.

Observing cleaning during the audit is an integral part of the efficacy of the cleaning process. The staff member undertaking the cleaning can be observed using the correct colour coding, following correct cleaning operating procedures, wearing correct uniform and personal protective equipment, using gloves and chemicals appropriately, adhering to safe ways of working and so on.

These audits are intended to provide assurance that cleaning standards are met using good practice methodology to satisfy infection prevention and control and safety standards. We recommend you only carry out efficacy audits where patients and visitors see the healthcare premises, and not in staff-only areas.

Prioritise functional risk areas that have not achieved safe standards consistently, or areas that have high rates of infection. The findings should be used to develop an improvement plan, which may include further training, investment in new equipment and materials, increased supervision, increased resources, changing the times of cleaning, performance management, etc.

Wherever possible, efficacy audits should be conducted in multidisciplinary teams between the staff responsible for cleanliness, nursing staff, infection prevention, and other estates and facilities colleagues to give a fully rounded view of the cleaning process. It is also good practice to invite patient representatives to take part in these audits from time to time.

Appendix 3 shows an example of an efficacy audit template. Note that the template can be changed to meet individual healthcare cleaning requirements and the organisation’s priorities.

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Efficacy audit frequency and scoring

We recommend that efficacy audits are conducted annually. Each organisation has the freedom to decide how to schedule the audits, for example, they could be undertaken monthly as a rolling programme so that a sample of areas of patient-facing areas are audited and at a time of day when cleaning is being undertaken.

Except for areas that are specifically being targeted for performance review, efficacy audits should be randomly selected, so that enough areas have an efficacy check to validate safe standards are being achieved. The actual quantity should be determined locally.

Each patient-facing area should be audited at least once each year. If an area falls below 80%, it should be re-audited within a reasonable timeframe until it achieves audit score of more than 80%.

The efficacy audit scores do not form part of, or contribute to, the technical audit percentage scores or the star-rating scores. The efficacy audits are intended to inform the healthcare organisation that correct training, infection prevention, health and safety, and safe systems of work, etc are being used. It is good practice to report the findings from efficacy audits at executive level to acknowledge good service, address poor service and drive continuous improvement.

Technology to determine the efficacy of cleaning outcomesConsideration should also be given to other audit technologies that include Ultraviolet (UV) gels, Adenosine Triphosphate (ATP), Black-lights and other technology to support the measurement and the efficacy of the cleaning process.

External assurance audits

External assurance audits are an intrinsic part of the auditing process and are recommended as good practice as they provide an independent view of cleanliness and validate the healthcare facilities’ own internally awarded technical and efficacy scores.

Collaborating with neighbouring facilities or NHS healthcare organisations is often the easiest way to get appropriately qualified staff or managers to take part in an external audit process. Professional associations may also provide qualified external auditors, as well as personnel involved in the Patient Led Assessment of the Care Environment (PLACE).

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External audit frequency

We recommend that an external audit is carried out annually. We also recommend you take a sample of audits across different functional risk categories.

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Audit reportingInformation technology plays an important part in the audit process, documenting findings and analysing failures, trends and results. Healthcare organisations that choose not to use information technology as part of the audit process should be able to use Excel spreadsheets that provide the same reporting format as an electronic system.

Factors to consider when developing or procuring an electronic audit tool include:

• the ability to match the facility and the needs of the environment and be simple to use; one size does not fit all

• the elements, frequency and room data capability for producing metrics to show compliance against the standard

• the ability to ‘build as you go’ to easily capture room function changes, new rooms etc

• the ability to easily build from plans

• the ability for data to be transferrable from one service provider to another (ownership of base data)

• easy export of data

• compatibility with NHS building regulation data

• simplified reporting functionality

• functionality to work in healthcare facilities with data device capability.

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PLACE and the National standards of healthcare cleanlinessPatient-led assessments of the care environment (PLACE) is an annual national inspection self-assessment programme, which is managed by NHS Digital on NHS England and NHS Improvement’s behalf. The assessments mainly apply to hospitals and hospices providing NHS-funded care in both the NHS and private/independent sectors, but other providers are encouraged and helped to participate in the programme. PLACE replaced the longstanding PEAT (Patient Environment Action Team) programme in 2013.

PLACE scores are released as an official statistic, and the results are published to help drive improvements in the care environment. The results show how healthcare organisations are performing both nationally and in relation to similar service providers.

Under PLACE, organisations make an in-depth assessment of the non-clinical, patient-related aspects of the care environment for all qualifying inpatient settings. Responses contribute to scores across six domains, including one specifically for ‘cleanliness’. Questions within some of the other domains also relate to cleaning and associated services.

Teams taking part comprise staff and patient assessors, who view settings from a non-technical (i.e. visual) and non-system focused approach, therefore giving a good indication of how patients and the public view standards.

In terms of cleaning, it is important that organisations reflect and react to PLACE scores and underlying action/improvement plans to make and maintain required and realistic improvements.

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Cleaning operating proceduresClean, safe healthcare environments make a vital contribution to patient safety as well as providing a clear public impression and expectation of quality care.

Cleaning, infection prevention and patient safety are all intrinsically linked. It is therefore vitally important to demonstrate good practice, knowledge, skills and performance to achieve the required standards of healthcare cleanliness.

The cleaning operating procedures include 50 environmental elements. Each element has been reviewed and will be periodically updated to incorporate the outcome of evidence-based environmental research, proactive infection prevention initiatives, collaboration with equipment and materials manufacturers, and staff training guidance.

As a ‘live digital document’, the aim is to provide healthcare facilities’ cleaning services with access to the latest guidelines to support good practice and enable constant quality improvement.

We recognise that the methodology used across organisations will vary according to type of building, location, activity, fabric and so on. It is therefore important that each healthcare facility undertakes its own risk assessment to determine which is the best methodology to use based on health and safety, effective use of resources, consideration of service users, and environmental factors, etc.

The cleaning operating procedures include references to traditional methods of cleaning as well as modern technical textiles and equipment. The selection of materials and their corresponding methods remain at the discretion of each facility.

However, we recommend that organisations minimise the use of abrasive pads as routine use will damage surfaces over time, which in turn will make them more difficult to clean and disinfect effectively. A disposable non-abrasive pad should be used to remove stubborn stains as a last resort and should not be routine practice.

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The full collection of cleaning operating procedures is available from the NHS Improvement estates and facilities portal. If you do not have access and have an NHS email address, please send your access request to: [email protected]

Examples of the cleaning operating procedures are shown in Appendix 7.

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mailto:[email protected]

GovernanceCleanliness standards have been in place for acute healthcare since the publication of the National standards for cleanliness in the NHS (2001).

The National standards of healthcare cleanliness 2019 require all healthcare organisations to meet safe standards of cleanliness to minimise risk to patient safety from inadequate cleaning.

Healthcare organisations should therefore have a strategic plan detailing how they will ensure a clean and safe environment for everyone using their healthcare facilities.

It is important that healthcare organisations develop cleaning policies for their organisations. These should cover all cleaning activity within the organisation and, where relevant, underlying specifications and procedures. These include all cleaning activities undertaken by the cleaning teams, as well as cleaning activities undertaken by the estates technical services staff and cleaning duties of clinical staff and other staff groups such as housekeepers, catering, laboratory and portering staff.

The policies need to identify the strategic aims and how, through liaison between the director of infection, prevention and control, facilities management and the infection prevention and control team, the requirements of the National standards of healthcare cleanliness will be met. The cleaning policy must be ratified by a relevant committee with board membership – i.e. infection prevention and control IPC committee.

The responsible board member should ensure that the staff responsible for cleaning understand their personal responsibilities and ensuring they develop systems and procedures that support good practice and delivery of the standard, implement and follow guidance and procedures, and ensure that staff also follow reasonable instructions and procedures, are trained in these procedures.

The local managers will provide updates on routine performance against the specific standards set to ensure the cleanliness meets the standards described in the organisations cleaning policy document

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Responsible departmental managers will be required to investigate substandard performance and report the actions taken to improve the standards to the appropriate committee, and provide assurance that any remedial action to provide continuous improvement is implemented, the committee will review any resource implications required to deliver changes to and improvements to the standards identified in the improvement plan.

Committee / board reports

Committee / board papers may include a list of all functional areas and the required cleaning performance score for each of the areas and the frequency of audit. The reports should detail the following information:

• actual percentage score against each functional area

• details of any areas that have failed to achieve a 5, or 4, star rating and the actions taken to improve the quality in the areas

• efficacy audit plan and scores against the plan with any areas for concern identified

• any recommended strategic changes for agreement by the committee / board including resource implications associated with the change

cleanliness audit scores and any areas where remedial action is required

assurance that star ratings are correctly displayed and updated

assurance that cleaning frequencies are displayed using the commitment to cleanliness charters

assurance that efficacy audits are carried out and that they meet the standards set and agreed and remedial action is taken to rectify any areas of non-conformance

that an annual external audit is undertaken to assure the quality and methodology adopted by the healthcare organisation

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Glossary Various terms in this guide have a specific meaning when used in relation to cleanliness in healthcare premises. These definitions are not exhaustive.

Dust includes lint, powder, fluff, cobweb.

Dirt includes mud, smudges, soil, graffiti, mould, fingerprints, ingrained dirt, scum.

Debris includes crisp packets, drinks cans and bottles, chewing gum, rubbish, cigarette butts, litter, adhesive tape, grit, limescale.

Element is an item within a functional area, or any part of the fabric or fittings of a functional area, which requires cleaning.

Functional area is a room or physically contiguous group of rooms deemed by a healthcare organisation to constitute an area of operation.

Spillage includes any liquid, tea stains, sticky substances.

Room types are a subset of functional areas. For example, on a ward these could be bedded bays and sanitary areas. This allows cleaning managers to more closely audit and manage standards in specific parts of functional areas.

Inputs are the resources used to produce and deliver outputs. Inputs may include staff, equipment or materials.

Low surfaces include items such as skirting boards, floor edges, low-level pipe work and trunking, low cupboard exteriors.

Middle surfaces include items such as grab rails, tables, trunking, desks, shelves, ledges, work surfaces, cupboard exteriors, window-sills.

High surfaces include items such as filing cabinets, curtain rails, locker and cupboard tops and picture frames.

Outcomes are the effect or consequences of the output: for example, cleaning (output) produces a clean and safe environment for patient care (outcome).

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Outputs are the actual product or service – for example, cleaning.

Performance parameter is the expected standard when cleaning is completed.

Processes are the procedures, methods and activities that turn the inputs into outputs – for example, mopping a floor.

Quality systems refer to integration of organisational structure, integrated procedures, resources, and responsibilities required to implement quality management. Taken together, these provide for the development of a comprehensive and consistent service.

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ReferencesStandards for better healthhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/

digitalasset/dh_4132991.pdf

Towards cleaner hospitals and lower rates of infectionhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/


A matron’s charter: an action plan for cleaner hospitalshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuida

nce/DH_4091506

Cleanliness matters – a regional strategy for improving the standardhttp://www.dhsspsni.gov.uk/cleanliness-matters-strategy-2005.pdf

Cleanliness matters toolkit – practical guidance for assessment of standards of environmental cleanliness in HSS trustshttp://www.dhsspsni.gov.uk/cleanliness-matters-strategy-2005.pdf

http://www.dhsspsni.gov.uk/index/hss/governance/governance-controls.htm

The revised healthcare cleaning manualhttp://nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?

AssetID=61814&type=full&servicetype=Attachment

Code of practice for the prevention and control of healthcare associated infections (Health Act 2006); Department of Health 2006 www.dh.gov.uk/en/Publicationsandstatistics/publications/PublicationsPolicyAndGuidance/DH_4139336

Towards cleaner hospitals and lower rates of infectionhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/


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http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4085861.pdf


http://www.dh.gov.uk/en/Publicationsandstatistics/publications/PublicationsPolicyAndGuidance/DH_4139336

http://www.dh.gov.uk/en/Publicationsandstatistics/publications/PublicationsPolicyAndGuidance/DH_4139336

http://nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=61814&type=full&servicetype=Attachment

http://nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=61814&type=full&servicetype=Attachment

http://www.dhsspsni.gov.uk/index/hss/governance/governance-controls.htm

http://www.dhsspsni.gov.uk/cleanliness-matters-strategy-2005.pdf

http://www.dhsspsni.gov.uk/cleanliness-matters-strategy-2005.pdf

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4091506






A matron’s charter: an action plan for cleaner hospitalshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuida

nce/DH_4091506

NHS Wales health circularsThe circulars provide streamlined, transparent and traceable method of communication between the department and the NHS. The circulars are divided into categories depicting a different area of health.NHS Wales Health Circulars

Health and care standardshttp://gov.wales/docs/dhss/publications/150511whc015en.pdf

Free to lead, free to carehttp://www.wales.nhs.uk/documents/cleanliness-report.pdf

Code of practice for the prevention and control of healthcare associated infectionshttp://gov.wales/docs/phhs/publications/140618appendixen.pdf

Commitment to purpose: eliminating preventable healthcare associated infections (HCAIs)http://wales.gov.uk/topics/health/publications/health/guidance/eliminating/?lang=en

The communicable disease outbreak plan for Wales (‘The Wales outbreak plan’)The Communicable Outbreak Plan for Wales

Antimicrobial resistance – a delivery plan for NHS Wales and its partnershttp://gov.wales/topics/health/nhswales/plans/amr/?lang=en

CQC cleaning outcome standard 15https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-15-

premises-equipment

National Services Scotland – standard infection control precautions literature review: routine cleaning of the care environmenthttp://www.nipcm.scot.nhs.uk/documents/sicp-routine-cleaning-of-the-environment-in-the-

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http://www.nipcm.scot.nhs.uk/documents/sicp-routine-cleaning-of-the-environment-in-the-hospital-setting/

http://www.nipcm.scot.nhs.uk/documents/sicp-routine-cleaning-of-the-environment-in-the-hospital-setting/

https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-15-premises-equipment

https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-15-premises-equipment

http://gov.wales/topics/health/nhswales/plans/amr/?lang=en

http://nww2.nphs.wales.nhs.uk:8080/HealthProtectionDomainDocs.nsf/($All)/196CFE33803CAB9880257CC20035954F/$File/Communicable%20Disease%20Outbreak%20Plan%20For%20Wales%20(vA15887986)ce.docx?OpenElement

http://wales.gov.uk/topics/health/publications/health/guidance/eliminating/?lang=en

http://gov.wales/docs/phhs/publications/140618appendixen.pdf

http://www.wales.nhs.uk/documents/cleanliness-report.pdf

http://gov.wales/docs/dhss/publications/150511whc015en.pdf

http://gov.wales/topics/health/nhswales/circulars/?lang=en



National Services Scotland – transmission-based precautions literature review: management of care equipment and environmental decontamination http://www.nipcm.scot.nhs.uk/documents/tbp-management-of-care-equipment-and-

environmental-decontamination/

Health Protection Scotland – literature reviews on emerging decontamination technologieshttps://www.hps.scot.nhs.uk/a-to-z-of-topics/decontamination/#publications

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https://www.hps.scot.nhs.uk/a-to-z-of-topics/decontamination/#publications

http://www.nipcm.scot.nhs.uk/documents/tbp-management-of-care-equipment-and-environmental-decontamination/

http://www.nipcm.scot.nhs.uk/documents/tbp-management-of-care-equipment-and-environmental-decontamination/

Acknowledgements

These standards were developed by healthcare professionals and cleaning subject matter experts from:

• The Association of Healthcare Cleaning Professionals

• Contractor provider partners

• Healthcare Estates and Facilities Management Association

• Health and Safety Executive

• Institute of Healthcare Engineering and Estate Management

• Infection Prevention and Control Society

• Royal College of Nursing.

Special thanks to David Griffiths, who has advised in the making of these standards as technical author of PAS:5748 and editor of the Revised healthcare cleaning manual.

Special acknowledgement to Yvonne Fortt and Lynne Evans for their tireless efforts in compiling this document.

We also thank all the people who dedicated their time and energy to producing this document, without whom it would not have been possible:

Emma Brookes, Head of Soft FM, Strategy and Operations, NHS Improvement and NHS England (Project Lead).

Thank you to Royal Derby Hospital for the commitment to cleanliness charter.

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Contact us:

NHS Improvement

0300 123 [email protected]

@NHSImprovement

NHS England

This publication can be made available in a number of other formats on request.

NHS Improvement publication code: X XX/19

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